Declaration-of-good-health-form (1).pdf

Policy Number:

FOR OFFICE USE ONLY

Received Date:

Declaration of Good Health Form Policy Details Details of the Life insured Name: Date of Birth:

D

D M M

Y

Y

Y

Y

Address:

City:

State Code:

PIN:

Name of Plan: Name of the Policyholder: Are you a US Citizen or US tax resident

Yes

No)

If Yes, Please provide TIN:

Policyholder Contact Details Landline No. (Residence):

0

Landline No. (Office):

0

*Mobile No.: (Mandatory)

0

Email ID: STD

Phone

I hereby agree that the statements below shall form part of my proposal for insurance and I declare that such statements together with the said proposal and declaration shall be the basis of the Policy between Bharti AXA Life Insurance Company Limited “the Company” and life insured “myself”. All communications will be on the e-mail id mentioned above (if available). The mode of communication from and to the company would include electronic mode like sms, email etc. Please tick 'Physical copy' if you want to receive communication in electronic form as well as physical Copy Physical Copy:

Q.No.

Details

1

Are you currently in good health? If “NO”, please elaborate in “details” section on page 2 along with copies of all investigations done by you.

2

Since the date of signing of the proposal, have you undergone any of the following? a) Hospitalisation b) Operation/Surgery c) Pathological examinations like blood test, X- ray, ECG, etc. If “YES”, please elaborate in “details” section on page 2 along with copies of all investigations done by you.

3

Have you consulted a doctor or specialist after the date of signing the proposal form? If “YES”, please elaborate in “details” section on page 2 along with copies of all investigations done by you.

4

Do you OR have you ever had, any of the following? If “YES”, state full details of each instance: a) High blood pressure or raised cholesterol, triglycerides. b) Heart disease. c) Diabetes or sugar in the urine. d) Any respiratory or lung disorder, e.g., asthma, bronchitis, tuberculosis, etc. e) Disease or disorder of kidneys, bladder or reproductive organs. f) Any disorder of the digestive system, gall bladder or liver. g) Any nervous disorder or mental condition, depression or psychiatric disorder. h) Paralysis, multiple sclerosis, epilepsy or stroke. i) Cancer, tumour, enlarged glands or enlarged lymph nodes. j) Anaemia, bleeding or blood disorders.

Declare GH Form 210 x 297 Front

Please tick any one Yes/

No

Yes/

No

Yes/

No

Yes/

No

Q.No.

Details k) l) m) n) o) p) q)

Please tick any one

Disorder or disease of muscles, bones, joints, limbs, spine. Urine, kidney, bladder, reproductive organ or prostrate disorders. Thyroid problems including goitre, hyperthyroidism or thyroiditis. Deformity or disability. Counselling or treatment or testing in connection with AIDS/HIV/other STDs. Ear, eye, nose or throat disorder. Accident or injury.

5

Are you currently: a) Taking any medication or prescription drugs not mentioned earlier ? b) Suffering from any physical disability, deformity, illness or injury that has kept you from working ? If “YES”, please elaborate in “details” section on page 2 along with copies of all investigations done by you.

Yes/ Yes/

No No

6

Do you have any health symptoms or complaints for which a physician has not been consulted or treatment received? e.g., persistent fever, unexplained weight loss, loss of appetite, pain, swelling, etc. If “YES”, please elaborate in “details” section on page 2 along with copies of all investigations done by you.

Yes/

No

7

Has any proposal or application for revival of Policy on your life made to the Company or any other life insurer ever been declined, postponed or accepted with an extra premium? If “YES”, please provide details on page 2.

Yes/

No

8

Have you travelled outside India or are you planning to travel outside India? If “YES”, please provide details on page 2.

Yes/

No

Q.No.

Details

Please tick any one

9

Is any proposal, or an application for revival of a lapsed Policy, on your life under consideration of the Company or any other life insurance company after the date of signing the proposal form? If “YES”, please provide details on page 2 (Company name, product applied for with Sum Assured).

Yes/

No

10

Since the date of signing of proposal, has there been any change in your occupation, financial position or annual income, vocation/hobbies?

Yes/

No

Yes/

No

Yes/

No

Yes/

No

For Female Life Insured only 11

Do you OR have you ever had any disorder of the female organs (breasts, ovaries, uterus), or any abnormality related to pregnancy or confinement, e.g., Caesarean section or miscarriage, high blood pressure, gestational diabetes, etc? If “YES”, please elaborate in “details” section below, along with copies of all investigations done by you.

12

Are you pregnant now? If “YES”, how many months?

13

When was your last baby born?

14

Have you ever had abnormal PAP smear test or CIN?

15

Any other information material for the evaluation of risk, kindly provide details -

months

Additional Information

If any of the above questions have been answered as “Yes”, kindly provide details (Please mention question number while providing details). Q. No.

Details

Since the date of my last proposal to Bharti AXA Life Insurance Company Limited, there has been no change in my health. • I declare that the above answers are correct to the best of my knowledge and belief. I declare that the answers/declarations given above shall be the basis of the insurance contract between Bharti AXA Life Insurance Company Limited and myself. If the answers/declarations contained herein are untrue, the said insurance contract shall be treated as null and void • I/we agree that the Company may provide/transfer/retain any information available with the Company related to me/us, obtained in connection with processing of my proposal or the policy and servicing thereof to any reinsurers, insurance association, medical registrar, statutory authorities/bodies or services providers engaged by the Company for policy servicing related activities without any further reference to me/us

Declare GH Form 210 x 297 Back

• I/we agree that the Company may share my/our information with other insurers for the underwriting and claims settlement purposes • I/we understand that i/we have an option to review and correct the information already provided or not to provide the data or information sought, also, at any time while availing the services or otherwise, i/we have an option to withdraw my/our consent for sharing of data given earlier, such withdrawal of the consent should be sent in writing to the Company. In the case i/we do not provide or later on withdraw my/our consent, the Company shall have the option not to provide me/us the services Signature/Thumb impression of Life insured

Signature/Thumb impression of Policyholder

Place:

Date:

D D M M Y Y Y Y

Vernacular Declaration DECLARATION IN CASE THIS DGH FORM IS FILLED BY A PERSON OTHER THAN THE POLICYHOLDER OR SIGNED IN VERNACULAR LANGUAGE: Declaration by Policyholder: I hereby declare that the contents in this form have been fully explained to me and I declare that whatever is stated hereinabove has been recorded as per the information provided by me. Thumb impression/Signature of the Policyholder  Declaration by person filling the form: I have explained the contents of this form to the Policyholder in ____________________ language and I have correctly recorded the answer provided to me. I further declare that the Policyholder has signed/affixed his/her thumb impression in my presence. Declarant’s Name: First Name

Middle Name

City

State

Last Name

Declarant’s Address:

Pin Code

D D M M Y Y Y Y

Date of Birth:

Date: Declarant’s Signature:

D D M M Y Y Y Y

Place:

*"The person giving this declaration can be any person other than Introducing Advisor or MOA or MOM"

Bharti AXA Life Insurance Company Ltd. Regd. Office: Unit No. 1904, 19th Floor, Parinee Crescenzo, 'G' Block, Bandra Kurla Complex, BKC Road, Behind MCA Ground, Bandra East, Mumbai -400051, Maharashtra Regn. No.: 130. CIN no: U66010MH2005PLC157108. Service address: Bharti AXA Life Insurance Company Ltd., Spectrum Tower, 3rd Floor, Malad Link Road, Malad (West), Mumbai - 400064.

1800-102-4444

SMS SERVICE to 56677 We will be in touch within 24 hours to address your query

Declare GH Form 210 x 297 Back

www.bharti-axalife.com

Comp-Oct-2010-1118AA